National Correct Coding Initiative

The Patient Protection and Affordable Care Act ((H.R. 3590) Section 6507 (Mandatory State Use of National Correct Coding Initiative (NCCI)) requires State Medicaid programs to incorporate "NCCI methodologies" in their claims processing systems by October 1, 2010.

The CMS originally developed NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payments in Medicare Part B claims. The purpose of the NCCI edits is to prevent improper payments when incorrect code combinations are reported. 

1. NCCI procedure-to-procedure edits that define pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons; and
2. Medically Unlikely Edits (MUE), units-of-service edits, that define for each HCPCS / CPT code the number of units of service beyond which the reported number of units of service is unlikely to be correct (e.g., claims for excision of more than one gallbladder or more than one pancreas).

CMS has allowed States flexibility in implementing the NCCI. States may consider edits on an individual State by State basis. That is, if a State has determined that some portion of the 1.3 million edits conflict with State laws, regulations, administrative rules and payments policies, CMS will allow State deactivation of edits.

This flexibility is granted until either April 1, 2011 or the State has an Advanced Planning Document (APD) approved by CMS that documents such conflict with State laws, regulations, administrative rules and payment policies.

In compliance with Section 6507 of the ACA, SoonerCare will activate the NCCI edits on April 1, 2011 for processing and payment of claims. Claims will be approved or denied on the basis of applicable NCCI/MUE edits.

Providers should be mindful of the NCCI/MUE edits when filing claims; however the SoonerCare policies and rules will remain the same. Additionally, providers will be able to request a claims review using the current OHCA process.

Please note that the NCCI/MUE edit methodology will impact outpatient and 1500 claims with  dates of service beginning October 1, 2010.

For more information and detailed listing of NCCI/MUE edits, please see the resources listed below:

• State Medicaid Directors letter on the CMS website
  
  
• CMS website with detailed information about NCCI
  
  
• OHCA form HCA -17 for claim review request
  
  
• Information on proper use of Modifier 59
  
  
• FAQ’s
  
  
• NCCI-associated Modifiers: 25, 27, 58, 59, 78, 79, 91, LT, RT, E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, RC, TA, T1, T2, T3, T4, T5, T6, T7, T8, and T9 are modifiers that providers may append to the column one or column two codes of a code pair edit.  If an NCCI edit has a modifier indicator of “1”, both the column one and column two codes are eligible for payment if one of these modifiers is appended to either code of the code pair edit.
  
  
• When modifier 25 is used with certain Evaluation and Management (E/M) visit codes (99202-99239, 99281-99285, 99304-99337, 99341-99350, 99381-99397, 99460, 99462, 99463, or 99477-99480) to indicate a significant, separately identifiable service was performed on the same day as one of the codes on this list, it will not be necessary to attach documentation to the claim for suspended medical review. 
  Modifier 25 Medical Review Bypass Code List
  
  
• When modifier 59, XE, XP, XS, or XU is used on one of the procedure codes on this list to indicate a significant, separately identifiable service was performed on the same day as another procedure code, it will not be necessary to attach documentation to the claim for suspended medical review.
  Modifier 59 Medical Review Bypass Code List

If you have any questions, please feel free to call OHCA Provider Services at 1-877-823-4529. Thank you.